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Neonatology Protocols King Edward Medical University/ Mayo Hospital Lhe


NEONATOLOGY PROTOCOLS

FLUID MANAGEMENT


Use the following as a guideline only. Be prepared to change it according to baby’s hydration status (puffy or dehydrated), urine output, electrolytes and renal function (urea & creatinine).

Weight (Kg)   Age (d)            Total Fluids                      Fluid Type
                                                      (ml/kg/d)                    
< 1.5                      1                      90                                plain 10% dextrose
                              2                      110                              D10+1/5th N Saline +
                                                                                          2ml KCL/ 100 ml
                              3                      120                              (same)
                              4                      140                              (same)
                              5                      150                              (same)

> 1.5                      1                      60                                Plain 10 % dextrose
                              2                      80                                D 10+1/5th N Saline +
                                                                                          2ml KCL / 100ml
                              3                      100                              (same)
                              4                      110                              (same)
                              5                      120                              (same)

Check serum Na / K of all babies on alternate days when on IV fluids.



“God is busy with the completion of your work, both outwardly and inwardly. He is fully occupied with you . Every human being is a work in progress that is slowly but inexorably moving towards perfection. We are each an unfinished work of art both waiting and striving to be completed . God deals with each of us separately because humanity is a fine art of skilled penmanship where every single dot is equally important for the entire picture”
----
Shams of Tabriz
ANTIBIOTIC POLICY
First line Antibiotics
1)      Babies admitted directly from Maternities or Clinics
          a)      Ampicillin 50 mg/kg/dose 8 hourly
          b)     Cefotaxime 50mg/kg/dose 12 hourly if age < 7 d
                 8 hourly if age > 7 d  or Amikacin 7.5mg/kg/dose 12 hourly
 2)  Babies admitted from Home
                        a) Ampiclox 200mg/Kg/d in 3 doses
                        b) Cefotaxime or Amikacin as above
Second Line Antibiotics
In the absence of culture report, select from following:
a)      Tanzo (piperacillin/ Tanzobactam) the pediatric dosage is according to piperacillin component. Neonates more than 2kg  75mg/kg IV 8hrly, less than 2kg 75 mg/kg IV 12hrly
b)      Tobramycin 4mg/kg/dose interval is according to the gestational age and post natal age, in term OD
c)      Vancomycin 10 mg/kg dose 8 hourly as slow infusion in 20 c.c N/S over 45 minutes
d)      Meropenem 20 mg/kg/dose 8 hourly as infusion in 20 c.c N/S over 30 min.
e)      Cefipime 25mg/kg/dose 8 hourly
Take blood culture sample before giving first shot if A/B.
All antibiotics should be given IV.
Adjust total fluids given per day while giving A/B as infusion.


GUIDELINES FOR PHOTOTHERAPY AND EXCHANGE TRANSFUSION
REFER to NICE GUIDELINES at the end of this document.


  • Use total billirubin.  Do not subtract direct billirubin.
  • Risk factors: hemolytic disease of NB, asphyxia, sepsis, hypothermia, acidosis, albumin below 3g/dl. If present, use lower levels.



NORMAL HEMATOLOGICAL VALUES IN NEW BORN



Pre-mature
Birth / term baby
D1
D3
D7
D14
1) HB (g/dl) (mean)
15
16.8
18.4
17.8
17
16.8
2) Retic Count (%)
3-10
3-7
3-7
1-3
0-1
0-1
3) White Cell Count (mm3)
5000-19000
10000-26000
13000-31000
5000-14000
5600-14500
6000-14000
4)Poly(X1000/mm3)
2-8
5-13
9-18
2-7
2-6
2-6
5) Platelets(mm3)
290000
290000
192000
213000
248000
252000



ROUTINE PROTOCOLS AT ADMISSION IN NEONATAL SECTION


1) Identify every baby from mother's or father's name. Fix two name tags as bracelets, along with Registration No: and Date of admission.

2) Secure photocopy of ID card of every baby's father / mother or near relative at admission and attach to patient's medical record.

2) Weigh every baby at admission, record weight in Grams. / Do BSL/.

3) Remove clothes and drape in clean open shirt and diapers.

4) Check vital signs: Temp, Pulse rate, Respiratory rate , B.P,  CRT,  sp02 and record in file.

5) Inspect Cord, apply spirit. If infected, paint with gentian violet 2%. Apply cord clamp if not applied already

6) Clean Eyes with saline swabs separately for each eye.

7) Place in a cot or warmer or Incubator as needed. Cover with clothes unless exposure is needed.

8) Adjust Incubator temp: according to body weight, postnatal age and clothed or naked. Adjust Incubator temp
(1kg=35-36C), (2 kg=34C) and (3 Kg=32 C)

9) Categorize every baby :  LBW, Premature with gestation age, SGA, AGA or LgA.

10) Record Vital Signs every 4 hours or 1-2 hourly to see trend if very sick.

11) Check Dextrostix reading at admission. If below 40 mg/dl, recheck every 1-2 hours.

12) Give 10% dextrose fluids IV to all babies if NPO, or give Enteral Feeding regularly.

13) Encourage Mothers to visit the baby to allow bonding, nursing care and feeding.

14) Encourage Breast Feeding on demand by manually expressed feeding by spoon, dropper or bottle,

15) Practice hand-washing on compulsory basis for all doctors, Nurses, paramedics and attendants. Do not practice drying with cotton towels. Dry in air or disposable  paper towels.

 16) Limit Entry of Infected persons in the Nursery.

17) Isolate babies with Diarrhea, skin diseases or with MRSA colonization.

18) For security reasons, at the time of discharge, baby will be handed over to real parents after their identification by the duty doctor and charge nurse during office hours. The parents will be asked to sign or fix thumb impression verified by Nurse.

19) Doctors will make a discharge slip and hand it to Staff nurse , who’ll then discharge the patient.

20) If pt. decides to Leave Against Medical Advice ( LAMA ) , follow the guideline stated earlier in this document.



NEONATAL ASPHYXIA


Evaluation
                                                                                             
1)      Apgar scoring if baby examined within 10 min of birth.
2)      Neurologic evaluation (sensorium, tone, reflexes, convulsions, ant: fontanelle, eyeball deviation)
3)      Signs of prematurity, IUGR, SGA, LGA
4)      Skin : meconium staining, jaundice, bruising, cyanosis
5)      Chest : (irregular, or shallow breathing, dyspnea with chest indrawing, crepts)
6)      Physical birth trauma if any/cephal hematoma/ caput succedaneum/ examine the cord.
7)      CVS : (murmur, cardiac failure)

Investigation

Blood sugar, CBC, Chest X-ray, ABG, Cranial USG, Cranial CT (if indicated)

Management (post-delivery care)

1)      Neutral thermal environment (warmer, incubator, wrapping in cot nursing)
2)      Vital signs including BP and saturation
3)      Oxygen therapy to prevent hypoxia
4)      IV fluids D10 solution : 2/3 daily fluid requirement
5)      Correct metabolic acidosis after ABG
6)      NG aspiration
7)      Vit K 1 mg IM stat
8)      Phenobarbitone to treat convulsions (20mg/kg slow infusion; if refractory, use additional drugs, maintain with 5mg/kg in 2 doses).
9)      Give antibiotic cover (Ampicillin+Cefotaxime) for possible sepsis.
10)  Give Mannitol (5ml/kg/dose 8 hourly) if signs of raised ICP obvious, or brain edema documented on USG.
11)  On recovery, give NG feeding in small amounts and increase gradually. Try oral feeds when sucking and swallowing reflexes present.



NEONATAL SEPSIS


EVALUATION

1)      Birth Events : Intrapartum maternal fever, prolonged rupture of membranes, CPR, chorioamnionitis, asphyxia, resuscitation, cord care
2)      Feeding practices : BF / FF
3)      Contact with infected persons
4)      H/O Lethargy, poor feeding, grey look, fast breathing, hypothermia (cold hands / feet)
5)      Full systemic examination.

INVESTIGATION

CBC, B:N ratio, Platelet count, CRP, ABG
Blood culture, Chest X-ray, LP (if indicated)

MANAGEMENT

1)      Monitoring Vital signs.
2)      NPO, NG aspiration
3)      Correct hypoglycemia if dextrostix < 40mg/dl. Give IV D10 2-4ml/kg as bolus, followed by D10 infusion.
4)       Correct hypocalcemia if symptomatic or serum level <7 mg/dl, with calcium gluconate 10% 2ml/kg dose(maximum 10 ml) in infusion over 45 minutes under Cardiac Monitoring ,  then add in daily fluids over 24 hours.
5)      Maintain neutral thermal environment (incubator, warmer)
6)      Maintenance fluids
7)      Correct acidosis after ABG
8)      If perfusion low (prolonged capillary refill), give IV push @ 20ml/kg then start Dopamine infusion 5-10 mcg/kg/min and/or add Dobutamine infusion 5-10 mcg/kg/min.
9)      Correct anemia (Hb<12.5gm/dl) with PCV 10 ml/kg, slowly over 2-3 hr.
10)  Antibiotics as per guidelines
11)  Feeding when tolerated, either via NG tube or give EBM or Formula feeds in increasing amounts.
12)  Platelet transfusion if indicated


PREMATURITY / LOW BIRTH WEIGHT BABY


EVALUATION

1)      Estimate gestational age from Ballard’s scoring between 24-72 hours; compare this to gestation expected from LMP.  Weight for Gestational Age. Categorize accordingly (SGA, AGA, LGA)
2)      Birth events, PROM, chorioamnionitis, antenatal steroids
3)      Feeding History
4)      Vital Signs (TPR, Saturation, Capillary refill time)
5)      Activity, hypothermia, fits, jaundice, cyanosis, malformation
6)      Physical examination (CNS, Resp, CVS, Abdomen, renal, malformations)


Investigation

CBC, Blood sugar, serum calcium, Chest X-ray, Cranial USG, blood culture

MANAGEMENT

1)      Maintain neutral thermal environment (use incubator, radiant warmer)
2)      Monitor vital signs regularly
3)      Vit K 1mg IM stat.
4)      Give oxygen via nasal catheter (0.5-1 lit/min) or head box (4 lit/min). Keep saturation 90-95%.
5)      Maintenance fluids as mentioned in the start of neonatology protocols.
6)      For suspected sepsis, take blood culture and start antibiotics empirically.
7)      For poor perfusion (prolonged capillary refill time CRT > 3sec), give Dopamine infusion 5-10 microgram / kg/min.
8)      In case of frequent apneas (duration > 20 sec, with bradycardia / hypoxemia), start aminophylline infusion . Load with 6mg/kg x i/v over 30min under cardiac monitoring , then maintain at 1-2 mg/kg/dose x 8H or 12 H .
9)      When stable, start feeding via NG tube (usually at 12-24 hr life). Even 1-2 ml milk will work as trophic feeds. If feeding reflexes are present, wt>1200 grams, gestation > 34 weeks and with no contraindication, start oral feeding via dropper/ spoon / feeding cup or soft nipple. Increase gradually, avoid vomiting / regurgitation.
10)  Encourage mothers to visit their babies in the nursery. Involve them in          routine care when possible. Encourage them to feed breast milk under      guidance.
11)  Monitor for complications

12 ) As a general Rule , If a P.T newborn is improving as stated earlier , take patient out to a Cot from incubator, and monitor for hypothermia hypoglycemia , and TRAIN their parents to give TENDER CARE LOVE ! If patient remain well , discharge may be done with advise to save from INFECTION, HYPOTHERMIA, GIVE FREQUENT FEEDS and FOLLOW UP in regular basis .
NEONATAL HYPOGLYCEMIA


EVALUATION

1) Screen all sick neonates at the time of admission with the help of dextrostix. The special categories include preterms, low birth weight, SGA, IDM, babies with asphyxia, suspected sepsis and neonatal convulsions.
2) Recheck and confirm hypoglycemia by lab estimation of venous blood if initial reading below 40 mg/dl in PreTerm and 54 mg/dl in Term neonates.
3) Suspect hypoglycemia in all high risk babies even when asymptomatic, symptoms of hypoglycemia like fits, sweating, pallor or drowsiness are very uncommon.

Management

1)      Give 10% dextrose 2-4 ml/kg IV bolus to correct hypoglycemia. Avoid hyperglycemia induced by giving 25% dextrose injections.
2)      Start D10 IV infusion @ 80 ml/Kg/d and recheck blood glucose regularly to detect hypoglycemia.
3)      Increase IV glucose infusion rate upto 150 ml/kg as required to keep blood glucose between 50-150mg/dl.
Or increase IV glucose concentration to 12.5-15% via central line. Investigate further.
4)      Use hydrocortisone or prednisone in refractory cases.
If hypoglycemia still persists , use Octreotide , Glucagon , or Diazoxide .
5)      Start milk feeding regularly as early as condition permits. Encourage breast feeding frequently.    





EVALUATION

1)      Information about mother’s diabetes status and treatment, obstetric history, h/o large babies previously, obstructed labour, symptoms of hypoglycemia
2)      Birth weight, gestation, cyanosis, jitteriness(oscillatory movements of limbs that stop once limb is held by physician , as compared to fits which continue to occur ) or fits, birth trauma, encephalopathy, respiratory distress, congenital malformation
3)      Screen all babies with dextrostix at birth or admission , then repeat at
½ , 1,2,3,6,12,24 and 48 hours. If low < 40mg/dl in Pre Tem and <54 mg/dl in Term , treat hypoglycemia.
4)      Initiate feeding early by formula feeds within ½ hour of life. Offer breast feeding early and frequently. Prevent hypothermia and keep warm.
5)      Check CBC, hematocrit, serum calcium and bilirubin levels.
6)      Anticipate special problems like respiratory distress syndrome, hypocalcemia(give I/V calcium for jitteriness), polycythemia, hyperbilirubinemia and congenital malformations of heart, spine and CNS, & GIT. Do detailed physical examination and get investigations like cranial USG, X- ray chest,    echocardiography .


Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.

NEONATAL TETANUS


EVALUATION

1)      Features like feeding difficulty, generalized flexor spasms esp: on stimulus, abdominal guarding, locked jaw, opisthotonus, conscious state, infected umbilical wound, circumcision or pierced ear.
2)       Ask birth events like mode and place of delivery and cord cutting practices by dais,
3)      Check immunization of mother against tetanus.


MANAGEMENT

1)      Maintain airway by posture and gentle suction.
2)      Avoid all stimuli. Keep in a noise free area with close monitoring.
3)      Maintain IV line with D10 N/5 saline at usual maintenance.
4)      Control fits with diazepam 0.3 mg/kg/dose slow over 1 min. Repeat dose 2-3 times if uncontrolled. If IV access not present, give diazepam per rectal in same dose after dilution with saline. 
5)      Antitetanus serum (ATS) 10,000 units IV stat without test dose. Or    Tetanus immune globulin 500 units IM stat.
6)      Give benzyl penicillin 200,000unit/kg/d in 3 doses IV, to control tetanus infection in the wound.
7)      For suspected sepsis, give antibiotics (as above)
8)      Clean wound / infected umbilicus with spirit and antiseptics like gentian violet or pyodine regularly.
9)      In case of apnea, see if it is caused by spasm. Give diazepam to control it. If no spasm, then bag with oxygen or intubate.
10)  Pass NG tube to remove secretions.
11)  Give phenobarbitone 5-8 mg/kg/d in two dose alternating with diazepam 1mg/kg/d in two doses orally, for control of fits on regular basis. In case of further fits, give diazepam IV on PRN basis.
When fits under control, start feeding with NG tube using EBM or formula milk and increase gradually.

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